COPD

Elena Bissell MD

Department of Family and Community Medicine

OBJECTIVES

bull Board Review Questions-get them ALL right

Recognize symptomsrisk factorsfindings of COPD

Become familiar with COPD staging and treatment guidelines

bull 126 million US citizens affectedbull Women account for 63 of COPD casesbull ~70 of COPD patients are younger than 65bull Genetic Predispositionbull Exposure to Smokingbull Only 15-25 of smokers develop COPDbull Alpha-1-antitrypsin deficiency is most common genetic disorder associated with COPDbull Airway obstruction

ndash Mucus hypersecretionndash Emphysema (disrupted alveolar attachements)ndash Mucosal and peribronchial fibrosis and inflammation

bull Respiratory Bronchiolitis is precursorndash Alveolar macrophagesndash Proteasesndash Cytokine mediators

bull History-Smoking exposure to smoke-Other socialoccupationalhobby exposures-alpha one antitrypsin deficiency

bull Symptomsndash Dyspneandash Cough with and without phlegmndash Fatiguendash Reduction in Activities of Daily Living

bull Dyspnea historyndash Onset of symptoms does not occur until FEV1 is down 50

FEV1FVC ratio lt70Incomplete or

no response to bronchodilator

Spirometry

Race based

bull Spirometry readings are calculated using age sex height and race

From ONE study (Lancet Respiratory Medicine 2013) a community based prospective study of 38k people-separating South Asian Southeast Asian East Asian African Middle East and North AmericanEuropean which states that it did not examine other factors including socioeconomic environmental or genetic factors

Spirometric Classification of COPDSeverity Based on Post-Bronchodilator FEV1bull Gold I Mild FEV1FVC lt 070

bull FEV1 gt 80 predicted

bull Gold II Moderate FEV1FVC lt 070bull 50 FEV1 lt 80 predicted

bull Gold III Severe FEV1FVC lt 070bull 30 FEV1 lt 50 predicted

bull Gold IV Very Severe FEV1FVC lt 070bull FEV1 lt 30 predicted or FEV1 lt 50 predicted plus chronic respiratory

SMOKING CESSATION AND OXYGEN ARE ONLY INTERVENTIONS THAT DECREASE OVERALL MORTALITY

Modified MRC dyspnea scaleGrade Symptom

0 I only get breathlessness with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 I walk slower than other people of the same age on level ground because of breathlessness or I have to stop for breath when walking on level ground

3 I stop for breath after walking about 100 meters or after a few meters on level ground

4 I am too breathless to leave the house or I am breathless when dressing or undressing

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

bull 126 million US citizens affectedbull Women account for 63 of COPD casesbull ~70 of COPD patients are younger than 65bull Genetic Predispositionbull Exposure to Smokingbull Only 15-25 of smokers develop COPDbull Alpha-1-antitrypsin deficiency is most common genetic disorder associated with COPDbull Airway obstruction

ndash Mucus hypersecretionndash Emphysema (disrupted alveolar attachements)ndash Mucosal and peribronchial fibrosis and inflammation

bull Respiratory Bronchiolitis is precursorndash Alveolar macrophagesndash Proteasesndash Cytokine mediators

bull History-Smoking exposure to smoke-Other socialoccupationalhobby exposures-alpha one antitrypsin deficiency

bull Symptomsndash Dyspneandash Cough with and without phlegmndash Fatiguendash Reduction in Activities of Daily Living

bull Dyspnea historyndash Onset of symptoms does not occur until FEV1 is down 50

FEV1FVC ratio lt70Incomplete or

no response to bronchodilator

Spirometry

Race based

bull Spirometry readings are calculated using age sex height and race

From ONE study (Lancet Respiratory Medicine 2013) a community based prospective study of 38k people-separating South Asian Southeast Asian East Asian African Middle East and North AmericanEuropean which states that it did not examine other factors including socioeconomic environmental or genetic factors

Spirometric Classification of COPDSeverity Based on Post-Bronchodilator FEV1bull Gold I Mild FEV1FVC lt 070

bull FEV1 gt 80 predicted

bull Gold II Moderate FEV1FVC lt 070bull 50 FEV1 lt 80 predicted

bull Gold III Severe FEV1FVC lt 070bull 30 FEV1 lt 50 predicted

bull Gold IV Very Severe FEV1FVC lt 070bull FEV1 lt 30 predicted or FEV1 lt 50 predicted plus chronic respiratory

SMOKING CESSATION AND OXYGEN ARE ONLY INTERVENTIONS THAT DECREASE OVERALL MORTALITY

Modified MRC dyspnea scaleGrade Symptom

0 I only get breathlessness with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 I walk slower than other people of the same age on level ground because of breathlessness or I have to stop for breath when walking on level ground

3 I stop for breath after walking about 100 meters or after a few meters on level ground

4 I am too breathless to leave the house or I am breathless when dressing or undressing

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

bull History-Smoking exposure to smoke-Other socialoccupationalhobby exposures-alpha one antitrypsin deficiency

bull Symptomsndash Dyspneandash Cough with and without phlegmndash Fatiguendash Reduction in Activities of Daily Living

bull Dyspnea historyndash Onset of symptoms does not occur until FEV1 is down 50

FEV1FVC ratio lt70Incomplete or

no response to bronchodilator

Spirometry

Race based

bull Spirometry readings are calculated using age sex height and race

From ONE study (Lancet Respiratory Medicine 2013) a community based prospective study of 38k people-separating South Asian Southeast Asian East Asian African Middle East and North AmericanEuropean which states that it did not examine other factors including socioeconomic environmental or genetic factors

Spirometric Classification of COPDSeverity Based on Post-Bronchodilator FEV1bull Gold I Mild FEV1FVC lt 070

bull FEV1 gt 80 predicted

bull Gold II Moderate FEV1FVC lt 070bull 50 FEV1 lt 80 predicted

bull Gold III Severe FEV1FVC lt 070bull 30 FEV1 lt 50 predicted

bull Gold IV Very Severe FEV1FVC lt 070bull FEV1 lt 30 predicted or FEV1 lt 50 predicted plus chronic respiratory

SMOKING CESSATION AND OXYGEN ARE ONLY INTERVENTIONS THAT DECREASE OVERALL MORTALITY

Modified MRC dyspnea scaleGrade Symptom

0 I only get breathlessness with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 I walk slower than other people of the same age on level ground because of breathlessness or I have to stop for breath when walking on level ground

3 I stop for breath after walking about 100 meters or after a few meters on level ground

4 I am too breathless to leave the house or I am breathless when dressing or undressing

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

FEV1FVC ratio lt70Incomplete or

no response to bronchodilator

Spirometry

Race based

bull Spirometry readings are calculated using age sex height and race

From ONE study (Lancet Respiratory Medicine 2013) a community based prospective study of 38k people-separating South Asian Southeast Asian East Asian African Middle East and North AmericanEuropean which states that it did not examine other factors including socioeconomic environmental or genetic factors

Spirometric Classification of COPDSeverity Based on Post-Bronchodilator FEV1bull Gold I Mild FEV1FVC lt 070

bull FEV1 gt 80 predicted

bull Gold II Moderate FEV1FVC lt 070bull 50 FEV1 lt 80 predicted

bull Gold III Severe FEV1FVC lt 070bull 30 FEV1 lt 50 predicted

bull Gold IV Very Severe FEV1FVC lt 070bull FEV1 lt 30 predicted or FEV1 lt 50 predicted plus chronic respiratory

SMOKING CESSATION AND OXYGEN ARE ONLY INTERVENTIONS THAT DECREASE OVERALL MORTALITY

Modified MRC dyspnea scaleGrade Symptom

0 I only get breathlessness with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 I walk slower than other people of the same age on level ground because of breathlessness or I have to stop for breath when walking on level ground

3 I stop for breath after walking about 100 meters or after a few meters on level ground

4 I am too breathless to leave the house or I am breathless when dressing or undressing

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Spirometry

Race based

bull Spirometry readings are calculated using age sex height and race

From ONE study (Lancet Respiratory Medicine 2013) a community based prospective study of 38k people-separating South Asian Southeast Asian East Asian African Middle East and North AmericanEuropean which states that it did not examine other factors including socioeconomic environmental or genetic factors

Spirometric Classification of COPDSeverity Based on Post-Bronchodilator FEV1bull Gold I Mild FEV1FVC lt 070

bull FEV1 gt 80 predicted

bull Gold II Moderate FEV1FVC lt 070bull 50 FEV1 lt 80 predicted

bull Gold III Severe FEV1FVC lt 070bull 30 FEV1 lt 50 predicted

bull Gold IV Very Severe FEV1FVC lt 070bull FEV1 lt 30 predicted or FEV1 lt 50 predicted plus chronic respiratory

SMOKING CESSATION AND OXYGEN ARE ONLY INTERVENTIONS THAT DECREASE OVERALL MORTALITY

Modified MRC dyspnea scaleGrade Symptom

0 I only get breathlessness with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 I walk slower than other people of the same age on level ground because of breathlessness or I have to stop for breath when walking on level ground

3 I stop for breath after walking about 100 meters or after a few meters on level ground

4 I am too breathless to leave the house or I am breathless when dressing or undressing

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Race based

bull Spirometry readings are calculated using age sex height and race

From ONE study (Lancet Respiratory Medicine 2013) a community based prospective study of 38k people-separating South Asian Southeast Asian East Asian African Middle East and North AmericanEuropean which states that it did not examine other factors including socioeconomic environmental or genetic factors

Spirometric Classification of COPDSeverity Based on Post-Bronchodilator FEV1bull Gold I Mild FEV1FVC lt 070

bull FEV1 gt 80 predicted

bull Gold II Moderate FEV1FVC lt 070bull 50 FEV1 lt 80 predicted

bull Gold III Severe FEV1FVC lt 070bull 30 FEV1 lt 50 predicted

bull Gold IV Very Severe FEV1FVC lt 070bull FEV1 lt 30 predicted or FEV1 lt 50 predicted plus chronic respiratory

SMOKING CESSATION AND OXYGEN ARE ONLY INTERVENTIONS THAT DECREASE OVERALL MORTALITY

Modified MRC dyspnea scaleGrade Symptom

0 I only get breathlessness with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 I walk slower than other people of the same age on level ground because of breathlessness or I have to stop for breath when walking on level ground

3 I stop for breath after walking about 100 meters or after a few meters on level ground

4 I am too breathless to leave the house or I am breathless when dressing or undressing

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Spirometric Classification of COPDSeverity Based on Post-Bronchodilator FEV1bull Gold I Mild FEV1FVC lt 070

bull FEV1 gt 80 predicted

bull Gold II Moderate FEV1FVC lt 070bull 50 FEV1 lt 80 predicted

bull Gold III Severe FEV1FVC lt 070bull 30 FEV1 lt 50 predicted

bull Gold IV Very Severe FEV1FVC lt 070bull FEV1 lt 30 predicted or FEV1 lt 50 predicted plus chronic respiratory

SMOKING CESSATION AND OXYGEN ARE ONLY INTERVENTIONS THAT DECREASE OVERALL MORTALITY

Modified MRC dyspnea scaleGrade Symptom

0 I only get breathlessness with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 I walk slower than other people of the same age on level ground because of breathlessness or I have to stop for breath when walking on level ground

3 I stop for breath after walking about 100 meters or after a few meters on level ground

4 I am too breathless to leave the house or I am breathless when dressing or undressing

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Modified MRC dyspnea scaleGrade Symptom

0 I only get breathlessness with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 I walk slower than other people of the same age on level ground because of breathlessness or I have to stop for breath when walking on level ground

3 I stop for breath after walking about 100 meters or after a few meters on level ground

4 I am too breathless to leave the house or I am breathless when dressing or undressing

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

CAT scaleAssessment of exacerbation risk

based on symptoms

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Combined Assessment of COPDPatient Characteristic Spirometry Exacerbationsy

earCAT (COPDassessment test)

mMRC(modifiedBritish Medical Research Council)

A Low riskLess symptoms

Gold 1-2(FEV gt50)

lt1 lt10 0-1

B Low riskMore symptoms

Gold 1-2(FEVgt50)

lt1 gt10 gt2

C High riskLess symptoms

Gold 3-4(FEV lt50)

gt2 lt10 0-1

D High riskMore symptom

Gold 3-4(FEVlt50)

gt2 gt10 gt2

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Group ASAMA or SABALABA

Group BLAMA or LABA-gtLAMA and LABA

Group C LAMA (found to reduce exacerbations)-gtLAMA and LABA

Group D ICS +LABA or ICS +LABA and LAMA

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Recommendations per GOLD Guidelines 2021Evidence Abull Vaccinations-pneumonia influenza and pertussis

bull Tobacco cessation

bull Oxygen in severe hypoxemia (88 at rest)

bull Regular use of ICS increases risk of PNA especially in severe disease

bull Long term use of oral glucocorticoids has numerous side effects DO NOT USE

bull Pulmonary Rehab improves dyspnea health status and exercise tolerance in stable pts

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Recommendations per GOLD Guidelines 2021Evidence Abull Bronchodilators (SAMA and SABA) improve symptoms and FEV1

bull LABA and LAMAs improved lung function dyspnea and reduce exacerbations

combo is more effective

bull ICS with LABA is more effective than individual components in improving lung fxnand reducing exacerbations

bull In Group D patients-PDE4 inhibitor improves lung fxn and decreases exacerbations

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

MS is a 56 yo female who is on albuterol prn for SOB related to her COPD She is now complaining of increasing symptoms of dyspnea and is using her inhaler up to 8 xday She hates it because it makes her heart race She is not having increased cough or sputum production You do spirometry on her and compare it to previous-her FEV1 was previously 80 of predicted and is now 60 of predicted

-What stage of COPD does she have-How should you manage her COPD

a schedule for lung transplantb stop albuterol and add a long acting anticholinergic once a day c add inhaled corticosteroid BID d oral steroids and antibiotics for exacerbation

-What other recommendations should be given to pt to reduce mortality

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

bull FEV at 60 with dyspnea and no increased sputum no exacerbations

Stage II based on FEV1 and group A based on symptoms

B stop SABA-gtLAMA or LABA

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

BB is a 60 yo male with COPD due to alpha 1 antitrypsin deficiency He is on continuous oxygen at 4L NC His FEV1 is 13 of predicted He is on a combination of inhaled corticosteroid and long-acting beta2 agonist He continues to feel very SOB and requests additional txt for symptom relief Has had multiple exacerbations this year

-What stage is his COPD

-What can you add for symptom relief

a add long acting anticholinergic

b oral steroids every day

c morphine for dyspnea

d change his medications to nebulizations for improved symptom relief

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

bull FEV lt30 very symptomatic and multiple exacerbations indicates Stage IV very severe copd Group D

A pt is on LABA-ICS-gtLABA-ICS plus a LAMA -gtconsider PDE4 inhibitor in addition if cost is not barrier

Symptom relief with SABA

Consider palliative options

DO NOT USE oral steroids if not exacerbation

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Which one of the following treatments is recommended in combination with inhaled corticosteroids for patients who have asthma and COPD

a Cromolyn

b Long acting muscarinic antagonists

c Methylxanthines (theophylline)

d Oral antihistamines

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

bull B-LAMA according to GOLD guidelines and 2018 Global initiative for asthma guidelines

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Spirometry can be used to monitor disease progression in COPD patients To be reliable what minimum interval is recommended

a 3 months

b 9 months

c 12 months

d 24 months

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

c 12 months

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

A 47 yo male presents with SOB and cough On PFT his FVC is lt80 predicted his FEVFVC is 90 predicted and there is no improvement with bronchodilator The diffusing capacity of lung for carbon monoxide (DCLO) is also low

Based on these results which one of the following is most likely to be the cause of this patientrsquos problem

a Asthma

b Bronchiectasis

c COPD

d Cystic fibrosis

e Idiopathic pulmonary fibrosis

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

bull e- idiopathic pulmonary fibrosis

Pt has restrictive pattern with low diffusing capacity All other choices would be obstructive pattern

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

Exacerbations

bull IV or PO steroids ndashusually burst but some patients benefit from taper

bull Antibiotics GOLD guidelines recommend 5-7 days of abx if pt has purulent sputum

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013

References

bull Lee H Kim J Tagmazyan K Treatment of stable chronic obstructive pulmonary disease the GOLD guidelines Am Fam Physician 2013 Nov 1588(10)655-63 663B-F

bull GOLD guidelines 2018 2021

bull Global differences in lung function by region (PURE) an international community-based prospective study Lancet Journal of Respiratory Med ARTICLES| VOLUME 1 ISSUE 8 P599-609 OCTOBER 01 2013